Michael Blaha, MD, MPH, director, clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University in Baltimore

Case by Case

Krumholz: I think it depends on the person. Someone with normal blood pressure may not benefit from going lower. In the case of salt, very high levels may, for some people, be associated with worse health outcomes. I think we are early in understanding who benefits most.

Gardner: Consider that in our national guidelines for vitamin and mineral intake, there is no RDA (recommended daily allowance) for sodium, only an amount not to exceed. There is no concern that Americans will get too little sodium, only a concern that most are getting more than is optimal for them.

Shelley: There is no need to drastically reduce sodium if a person's blood pressure is under control (without medicine).

Kaplan: I believe that in general people should reduce their salt intake. That said, guidelines don't apply to everyone and there are clearly patients who are not at as high risk for hypertension and other complications that can be exacerbated by excess dietary salt. The problem is that it is much easier to put out a guideline that covers everyone than one that is more nuanced.

Johnson: Lowering the sodium content in processed food could help lower sodium consumption on a population basis. For persons who are salt sensitive, lowering sodium consumption may help lower blood pressure and reduce risk of hypertension. There may be risks for very low-sodium diets, however. Our research from the Women's Health Initiative study has suggested that higher sodium consumption is associated with a reduced risk of hip fracture.

Moran: People with high blood pressure stand to benefit from lowering salt in their diets. Ideally, this would be the only group that lowers salt intake to control high blood pressure. However, high salt content is so common in the food we purchase, and following a special diet is difficult for most people. A population-wide dietary salt lowering approach is a practical way to lower blood pressure in those at risk -- as long as the low risk, normal blood pressure group is not harmed in any way.

Industry Must Cooperate

Shelley: The impact of the FDA guidelines to reduce salt will be gradual. We need some sodium -- just not as much as most of us get.

Kaplan: Ultimately it would be better for the majority of people to have less dietary salt and processed foods, but the issue becomes access to fresh food, produce, vegetables, etc. It is much easier (patient convenience as well as economically) to get a can of peas or another vegetable than to find and then prepare fresh produce. If people will purchase food (commercial or fresh) that has the imprimatur of the FDA or government guidelines, then companies will provide that product, but in a free-market economy it won't happen without financial incentive.

Simpler: One of the reasons that there is so much salt in processed foods is to make it taste good enough so that people will buy it again and again. The food industry is going to fight it because processed food will not taste as good without it.

Gardner: Past efforts to create "lower sodium" products by the food industry, and announce that on packaging, has often led to lower sales as a result of the impression that the lower the sodium the more bland. I do think the FDA guidance will lend support to a growing, meaningful response in the food industry, and accelerate the progress being made.

Krumholz: I hope that it will help to lower high salt foods that can be just as flavorful without the salt. It is possible that many foods could be just as good with less salt -- and the industry should be challenged to use the least amount necessary, because it is possible that some of their customers are salt sensitive.

Gardner: Given that these are voluntary guidelines for the food industry, one could be snarky and skeptical and reply that it won't accomplish anything if it means Americans will buy less of their food products.

Changing Consumer Wants

Shelley: If salt is gradually reduced, the taste buds readjust to the new level, the desire is lower, and the person does not even realize it has happened. Using spices and wine to flavor foods is great way to transition and stop using salt when cooking helps as well. Small changes makes anything possible. Most people know the old saying you do not learn to walk before you crawl -- small changes make the body adapt.

Gardner: Given that about three-fourths of the sodium in the average American's diet comes from processed packaged foods, the biggest impact will come from decreasing the sodium levels in the foods Americans choose where they don't add the salt themselves. Rather than simply "taking away some of the salt," chefs and the culinary profession will have to have the mindset that they are finding creative ways to enhance flavor profiles by drawing on spices and herbs from the exciting variety of cultural cuisines from across the while doing so without adding as much sodium as they were previously.

Blaha: Getting the average person to reduce salt intake is complicated. But it starts with changes in pre-prepared foods and more education about the effects of salt on blood pressure.

Moran: Behavior change is hard. That is why a population-wide dietary salt lowering approach is attractive to public health policy makers. But is also possible that the public can change their dietary salt expectations, and their demands on food companies could also change salt content in prepared foods. It is important to keep in mind though that cultural shifts like that are slow to evolve -- just look at how long it took to reduce smoking rates.

Krumholz: The point is not to use salt mindlessly -- and it seems likely that steering away from processed foods has a lot of reasons to recommend it. I think we should not make everyone worry about salt; but rather be mindful of it and use it when it delivers value in terms of flavor.

Kaplan: We all can make short-term changes, but for meaningful health impact this has to be long-term and something that you "buy into." I'm not an advocate for giving patients more medications unnecessarily, but if ultimately if a lifestyle change will make someone unhappy (and make those around them unhappy), then it may not be the best option. For things like dietary changes, I think what works best is slow, steady and incremental. So it is not an absolute number or amount of sodium that is reduced, but the percentage decrease and can it be sustained.

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